ICU Stories - Atrial fibrillation: A few days ago, when I came on service, I took care of a 70 yo patient who had been in the ICU for ~15 days. He had been admitted with an intra-abdominal abscess secondary to colonic perforation. He had undergone colectomy and required twice percutaneous drainage of abscesses. His course was complicated by acute kidney injury requiring continuous renal replacement therapy and hypoxemic respiratory failure requiring high-flow nasal cannula and NIV During his ICU stay, he had developed new-onset atrial fibrillation with rapid ventricular response (heart rates persistently in the 130-150 bpm range). He was largely asymptomatic aside from occasional palpitations but remained on vasopressor support with norepinephrine (0.05-0.15 mcg/kg/min) and vasopressin 0.04 u/min For more than 5 days, Cardiology, Electrophysiology, and the ICU team had attempted multiple rate-control strategies, including low-dose beta-blockade, amiodarone boluses and infusion, digoxin, and diltiazem boluses and infusion. None achieved adequate rate control, let alone conversion to sinus rhythm. The prevailing concern was that, because the patient remained septic (he had leukocytosis and some worrisome abdominal fluid collections), cardioversion would be unlikely to succeed Reversible triggers had been addressed: his oxygenation was adequate, his pain was controlled, and his electrolytes were within acceptable limits. However, the persistent tachy-arrhythmia created a practical problem. Each time fluid removal was attempted through CRRT, the heart rate made both the ICU and Nephrology teams very hesitant to proceed. As a result, patient kept accumulating a positive fluid balance day after day, reaching approximately 15 liters positive by the time I first evaluated him After reviewing his course and reassessing his physiology, I decided that cardioversion was worth attempting. To the surprise (?) of the Cardiology and Electrophysiology teams, synchronized cardioversion with 100 joules restored sinus rhythm. He has remained in sinus rhythm for the past week. The change was clinically meaningful. We were able to discontinue both vasopressors and achieve negative fluid balance each day thereafter This is, of course, a single case (a N-of-1 study) rather than definitive evidence. But it reinforced an important lesson for me: in Critical Care, “sepsis-related” AF does not always mean “do nothing.” If the rhythm is contributing to shock, organ dysfunction, or blocking essential therapy, a carefully considered rhythm-control attempt may reveal a missed opportunity to help #foamed #foamcc Circulation. 2023;147:e676-e698 DOI: 10.1161/CIR.0000000000001133